Raymons Charles Thomas, Sr.
February 14, 1999
contributed by Ron
Renquin
DEPARTMENT OF HEALTH AND SOCIAL SERVICES
ORIGINAL CERTIFICATE OF DEATH
STATE FILING DATE APR
02 92 008543
STATE DEATH NO.
LOCAL FILE NUMBER
1. DECEDENT'S NAME First
Full Middle Last
Raymond Charles THOMAS SR.
2. SEX
M F
X
3. SOC. SEC. NUMBER OF DECEDENT
357-20-6718
4a. PRONOUNCED DEAD DATE:
Mo Day
Yr
March 22,
1992
4b. HOUR:
Hour
8:10 A
M
5. BODY FOUND
24+ hours after death
Y X
N
6a. AGE (Years)
(Last Birthday)
63
b. Under 1 yr.
Mos
Days
c. Under 1
day
Hours
Min
7. DATE OF BIRTH Mo. Day
Yr.
Aug 10, 1928
8a. COUNTY OF DEATH
Wood
8b. DEATH OCCURRED INSIDE
CITY, VILL.
TOWNSHIP
Town of Remington
8c. (CHECK ONE)
City
Vill. Twnship
X
9. DEATH AT HOSPITAL
1. Inpat.
3. DOA-From Nur. Hm. 5.
DOA-From Other
2.
Outpat. 4. ER-From Nur.
Hm. 6. ER-From Other
10. OTHER PLACE
N.H.
Other
X Res. of deceased
11a. HOSPITAL (AND CAMPUS) OR NURSING HOME
(If not Hospital or Nursing Home give street address)
1041 Necedah Road
11b. NURSING HOME
LICENSE NO.
12. MARITAL STATUS
X
Married Never
Married
Divorced Widowed
13a. RESIDENCE - STATE
Wisconsin
13b. RESIDENCE COUNTY
Wood
13c. RESIDENCE - INSIDE CITY, VILLAGE, TOWNSHIP
Town of Remington
13d. (CHECK ONE)
City
Vill. Twnship
X
14a. NUMBER, STREET
1041 Necedah Road
14b. ZIP CODE
54413
15. STATE OF BIRTH (Country if not in U.S.)
Illinois
16. FATHER'S NAME: First
Middle Last
John Andrew Thomas
17. MOTHER'S NAME: First
Middle Birth Surname
Bessie Ethel
Trout
18. RACE (e.g. White, Black, Am. Indian, etc.)
White
19. HISPANIC ORIGIN? Specify Cuban, Mexican, etc.
X No
20a. USUAL OCCUPATION (Do not enter "Retired")
Station Master
20b. KIND OF BUSINESS / INDUSTRY
Railroad Business
21. EDUCATION Highest grade completed
Elem/sec (0-12) College
(1-5+)
8
22. DECEDENT EVER IN U.S.
ARMED FORCES?
X YES
NO
23. SURVIVING SPOUSE (If wife, give birth surname,
not married surname)
(First, Middle,
Last)
Patricia Ryan
24a. INFORMANT'S NAME
Patricia Thomas
24b. MAILING ADDRESS Street
City/Village
State
ZIP
1041 Necedah Road Babcock, Wisconsin
54413
25. METHOD OF DISPOSITION
Entomb. Burial Cremation
Donation
X
26. PLACE OF DISPOSITION (Name of cemetery, crematory,
or other place)
Wood National
Cemetery
27. LOCATION City/Village/Township
State
Milwaukee,
WI
28. DATE SIGNED BY FUNERAL SERVICE LICENSEE
(Mo., Day,
Yr.)
March 23,
1992
29. DATE RECEIVED FROM MED. CERT.
(Mo., Day,
Yr.)
March 31,
1992
30a. FUNERAL SERVICE LICENSEE (or person acting
as such.)
Signature Michael A. Ritchay
30b. WI. LICENSE NO.
4709
31. NAME AND MAILING ADDRESS OF FACILITY
(Street and
number, City, State, Zip)
Ritchay Funeral
Home
1950
12th Street So Wisconsin Rapids, WI 54494
32.
MEDICAL
CERTIFIER
(Check one)
X CERTIFYING PHYSICIAN - To the best of
my knowledge death was
pronounced and occurred
at the time(s) and due to the causes stated.
CORONER/M.E. - On the
basis of examination and/or investigation, in
my opinion, death was
pronounced and occurred at the time(s) and
due to the causes and
manner stated.
33. DATE OF DEATH (Mo., Day, Yr.)
3/22/92
34. AUTOPSY PERFORMED?
YES X
NO
35a. MEDICAL CERTIFIER SIGNATURE & TITLE (Black
Ink)
Charles Earl Wirtz MD
35b. DATE SIGNED (Mo., Day, Yr.)
3/27/92
36a. MEDICAL CERTIFIER'S NAME
Charles Earl Wirtz MD
36b. WI. PHYSICIAN LICENSE NO.
(If Physician)
26899
37. CERTIFIER'S MAILING ADDRESS (Street &
Number, City, State, ZIP)
1000 N
OAK MARSHFIELD WI
54449
38. MANNER OF DEATH
1. X Natural
4. Homicide
2.
Accident. 5.
Undet.
3. Suicide
6. Pending
39. DATE OF INJURY (Mo., Day, Yr.)
40. HOUR OF INJURY
M
41. PLACE OF INJURY (Home, Street Farm, etc.)
Specify
42. INJURY AT WORK?
YES
NO
43a. LOCATION Street or RFD, City or Vill., and
State in which injury occurred
43b. COUNTY
44. REGISTRAR SIGNATURE
Rene L. Krause
45. DATE RECEIVED BY REGISTRAR (Mo., Day, Yr.)
MAR 31 1992
46. PART I. Enter the diseases, injuries
or complications that caused the death.
Do not enter
the mode of dying such as cardiac or respiratory arrest, shock
or heart failure.
List only one cause on each line. Do not list old age or
senility as
sole cause.
(Final disease or condition
Interval between
resulting in death.)
onset and death
IMMEDIATE CAUSE
(a) Respiratory Failure
24 hours
Sequentially list conditions if
any, leading to immediate
cause. ENTER UNDERLYING
CAUSE LAST. (Disease or
injury that initiated events
resulting in death)
(DUE TO OR AS A CONSEQUENCE OF):
(b) COPD
6 months
(DUE TO OR AS A CONSEQUENCE OF):
(c)
(DUE TO OR AS A CONSEQUENCE OF):
(d)
PART II Other significant conditions
contributing to death but not resulting in
underlying cause given in Part I.
47. IF INJURY, DESCRIBE HOW INJURY OCCURRED
* The entries have been transcribed exactly from the original
so that any
misspelling or errors of a person's name, place
name, date, or any other
entry
|
Patricia Ann Ryan Thomas
February 14, 1999
contributed by Ron
Renquin
DEPARTMENT OF HEALTH AND FAMILY SERVICES
ORIGINAL CERTIFICATE OF DEATH
STATE FILING DATE MAR
10 99 008042
STATE DEATH NO.
LOCAL FILE NUMBER 1113
1. DECEDENT'S NAME First
Full Middle Last
Patricia
THOMAS
2. SEX
M F
X
3. SOC SEC NUMBER OF DECEDENT
395-24-5602
4a. PRONOUNCED DEAD DATE:
Mo
Day Yr
February 14,
1999
4b. HOUR
Hour
5:00 A
M
5. BODY FOUND
24+ hours after death
Y
X N
6a. AGE (Years)
(Last Birthday)
70
b. Under 1 yr.
Mos
Days
c. Under 1 day
Hours
Min
7. DATE OF BIRTH Mo. Day
Yr.
November 05, 1928
8a. COUNTY OF DEATH
Milwaukee
8b. DEATH OCCURRED INSIDE
CITY, VILL.
TOWNSHIP
Milwaukee
8c. (CHECK ONE)
City
Vill. Twnship
X
9. DEATH AT HOSPITAL
1. X Inpat.
3. DOA-From Nur. Hm.
5. DOA-From Other
2.
Outpat. 4.
ER-From Nur. Hm. 6.
ER-From Other
10. OTHER PLACE
N.H.
Other
Res. of deceased
11a. HOSPITAL (AND CAMPUS) OR NURSING HOME
(If not in Hospital or Nursing Home give street address)
St. Luke's Medical Center
11b. NURSING HOME
LICENSE NO.
12. MARITAL STATUS
Married
Never Married
Divorced X Widowed
13a. RESIDENCE - STATE
Wisconsin
13b. RESIDENCE - COUNTY
Wood
13c. RESIDENCE - INSIDE CITY, VILLAGE, TOWNSHIP
Remington
13d. (CHECK ONE)
City
Vill. Twnship
X
14a. NUMBER, STREET
1031 Necedah Road*
14b. ZIP CODE
54413
15. STATE OF BIRTH (Country if not in U.S.)
Wisconsin
16. FATHER'S NAME First
Middle Last
Vance Ryan
17. MOTHER'S NAME First
Middle Birth Surname
Edna Lucht
18. RACE (e.g. White, Black, Am. Indian, etc.)
White
19. HISPANIC ORIGIN? Specify Cuban, Mexican, etc.
X No
20a. USUAL OCCUPATION (Do not enter "Retired")
Homemaker
20b. KIND OF BUSINESS / INDUSTRY
Own home
21. EDUCATION Highest grade completed
Elem/sec (0-12) College
(1-5+)
12
22. DECEDENT EVER IN U.S.
ARMED FORCES?
YES X
NO
23. SURVIVING SPOUSE (If wife, give birth surname,
not married surname)
(First, Middle,
Last)
24a. INFORMANT'S NAME
Michael V. Thomas
24b. MAILING ADDRESS Street
City/Village
State
ZIP
2432 S. Howell Avenue Milwaukee WI
53207
25. METHOD OF DISPOSITION
Entomb.
Burial Cremation Donation
X
26. PLACE OF DISPOSITION (Name of cemetery, crematory,
or other place)
Wood National
Cemetery
27. LOCATION City/Village/Township
State
Milwaukee
WI
28. DATE SIGNED BY FUNERAL SERVICE LICENSEE
(Mo., Day,
Yr.)
February 15,
1999
29. DATE RECEIVED FROM MED. CERT.
(Mo., Day,
Yr.)
March 1, 1999
30a. FUNERAL SERVICE LICENSEE (or person acting
as such)
Signature James A Sass
30b. WI LICENSE NO.
3685
31. NAME AND MAILING ADDRESS OF FACILITY
(Street and
number, City, State, Zip)
Max A. Sass
& Sons Funeral Home
1515 West
Oklahoma Avenue, Milwaukee, Wisconsin 53215-4603
32.
MEDICAL
CERTIFIER
(Check one)
X CERTIFYING PHYSICIAN - To the best of
my knowledge death was
pronounced and occurred
at the time(s) and due to the causes stated.
CORONER/M.E. - On the
basis of examination and/or investigation,
in my opinion, death was
pronounced and occurred at the time(s) and
due to the causes and
manner stated.
33. DATE OF DEATH (Mo., Day, Yr.)
Feb 14, 1999
34. AUTOPSY PERFORMED?
YES
X NO
35a. MEDICAL CERTIFIER SIGNATURE & TITLE (Black
Ink)
VK Rao M.D.
35b. DATE SIGNED (Mo., Day, Yr.)
Feb 15th 1999
36a. MEDICAL CERTIFIER'S NAME
V.K. Rao M.D.
36b. WI. PHYSICIAN LICENSE NO.
C/ME code
20251
37. CERTIFIER'S MAILING ADDRESS (Street &
Number, City, State, ZIP)
3201 S. 16th
Street, Milwaukee, WI 53215
38. MANNER OF DEATH
1. X Natural
4. Homicide
2. Accident.
5. Undet.
3.
Suicide 6.
Pending
39. DATE OF INJURY (Mo., Day, Yr.)
40. HOUR OF INJURY
M
41. PLACE OF INJURY (Home, Street Farm, etc.)
Specify
42. INJURY AT WORK?
YES
NO
43a. LOCATION Street or RFD, City or Vill., and
State in which injury occurred
43b. COUNTY
44. REGISTRAR SIGNATURE
Seth F Foley
MD CHO
45. DATE RECEIVED BY REGISTRAR (Mo., Day, Yr.)
MAR 5 1999
46. PART I. Enter the diseases, injuries
or complications that caused the death.
Do not enter
the mode of dying such as cardiac or respiratory arrest, shock
or heart failure.
List only one cause of death on each line. Do not list old
age or senility
as sole cause.
(Final disease or condition
Interval between
resulting in death.)
onset and death
IMMEDIATE CAUSE
(a) CONGESTIVE HEART FAILURE
Long standing
Sequentially list conditions if
any, leading to immediate
cause. ENTER UNDERLYING
CAUSE LAST. (Disease or
injury that initiated events
resulting in death)
(DUE TO OR AS A CONSEQUENCE OF):
(b) CORONARY ATHEROSCLEROSIS*
Long standing
(DUE TO OR AS A CONSEQUENCE OF):
(c)
----
----
(DUE TO OR AS A CONSEQUENCE OF):
(d)
----
----
PART II Other significant conditions
contributing to death but not resulting in
underlying cause given in Part I.
DIABETES MELLITUS
47. IF INJURY, DESCRIBE HOW INJURY OCCURRED
----
* The entries have been transcribed exactly from the original
so that any
misspelling or errors of a person's name, place
name, date, or any other
entry |
|